21561 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification \� PERMIT NO.
BuRding Address:
c/ - / 21561
q{ �O e Pao/
wmrs ame: one: hUH.Milp
L UAIL
erLJ0C-j1C1Wkpeq CITY OF CUPERTINO-BUILDING DIVISION
Con ORpr•a N.mEK _ a t e.No: APPLICATION I PERMIT
/ NI Nne, BUILDINC-Q.FLTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
Archltecr .Engineer: Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreae:
1:1I LICENSED
EDCODECLARATION
IPERMIT
ISSUANCE E:1 �1:1/t/
he affirm that Beensedunder
provisions ChcoAPPLIANCESRFSTDENTIAL
inthion7OD)ofDio3oftheBugneeandPro(essionsCoeandmy JOB DCRI'TO
N
license is In forceand effect. PANELS
LicenseCheo 9 ��
Dae - CmdmctH
—q#CHITECPS DECLARATION 281'1000 AMT'S
ippi++��e4 O I understand my paw shall be used as public records. OVER 1000 AMPS SQ.Ff.FLOOR AREA $/SQ.FT.
E Fj Ucenac'd Professional SIGNSELECTRICAL
G�6, OWNER-BUILDER DECLARATION
HurebyaffsmnthatI am exempt from the Contractoh License Lawforthe SPFJCIALCItCLZT/MLSC
7.0 '� following reason.(Section 70315,Business and Protesabns Code:Mycity or
O Z t•u9 TEMP.METER OR POLE INST.
C,S following reason.
Pmfpmvm Cod :Anycityor
a anystmc mprlortottsi mance,aMrequimstheapphmntfwsuchpermitto POWER DEVICES
py U file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Low(Chapter 9(commencing with Section 7000)of Divi- gWQ.tMONG POOL ELECTRIC
slon3ofthe Busiassand Profmiom Code)orthathelaewmpttherefmmand VALUATION
the basis for the alleged exemption. Any violation of Section 70)1S by any
aPpU..t fora permit subjectstheapphcant to a civil penalty of not more than OUTLETSSWITCHESSFIXTURFS
Ove hundred dollars($SM. NEW RESIDENTIAL ELECTR
F1 1,as owner of the property,or my employees with wages as their sole e'Q�T. STORIES TYPE CONSTRUCTION
�7< compensation,w0l do the work,and the structure Is not Intended or offeredfor
�' ❑
sale(Sm.70LI,Busineas and Professions Code:The Contractor.Lim.Law
�s$ does not apply to an owner of property who builds or improves thereon,and
who does such work himself orthrough his own employees,provided that such OCC.CROUP AES.UNITS
Improvemm sarcnoHntendedoroffered forsale.If,howevegthebuildingor TOTAL:
Improvement issold withinoneyearo(comple lon,theowner-bu0derwill have
tis rdenofpmving that he did nm build or improve forpurpose ofsele.). QTY, PLDMBIN E FEE FLOOD ZONE APN
L as owner of the property,am exclusively contracting with licensed pFRM17ISSUANCE
contractors to cmnswct the pmject(Sec.7054,Business and Professions Code:
ILe Contractor's License law does not apply to an owner of property who pLTQtID IN&VENT-
Wild, or w
Improves thereon, and ho contracts for such paoje with a
0 tt[actor(s)Bcensed pursuant to the Contractor's License Law. gpIX WPADTFGT. CE FEE SUMMARY
LI I am exempt under Sec. B A P C for this mason
Owner Date DRAINS RR F. SANITARY Y_ NOUTSID. .
Ere
WORIONAN COMPENSATION DECLARATION RECEIT N
❑f hereby affirm that I have a certificate of consent to self-Insure,ne a FIXTURES USCHOOLTAX Yomifleste ofWorkeriCompensation Insurance ora certified copy Ommed(Sec. RECEIPT N
3808,lab CJ GAS EA. C40 PARK S Y N
Policy M GAS EA.SY RECEIPT
CoN
m any BUILDING DIVISION FEES
rtlfid copy is hereby(umland. GREASE/ USRtL WASTE PLANCI-IECK FEE
fled Eyes If with the city Inspection division.
'I'1LA1e�'IONU0N 4YORKERS'' GREASETRAP PAID
COMPENSATION INSURANCE
(fhlssection need not Wcompleted Btheperrod isforons hundred dollars SEWER-SANITARY- RM EA.2WFT. r Date ReCCI t#
($108)or less.)
Icertify that in the performance of the work for which this pemNt is issued, WATER IIEATERW/ FNT/ELECTR ENERGYFEE Y_ N
1 shall not employ any person in any manner so as to become subject to the
workers'Compensation laws of C difomh.Date WATER SYSTEM/TREATING PAI D
O Z Applicant
Z O NOTICE TO APPLICANT If,after ouUmg this CcrtBlate of Exemption,you NEIN RESIDINTIAL PLMB. SQ2 . NAX
ate Recei t#
shouldbemm subjedto Ne Wor m'Compeaatiwpmvulomofthe Labor TOTAL:
LU~ N Code,you most forthwith complywlth such provision orthis permit shall be
> deemed revoked. G "O CONSTRUCTION LENDING AGENCY FEEI herebyaffirmthat there is a construction Inedingagency forthe peAorm- TOTAL: C FEEZ arm of the work for which this permit is issud(Sec.3097,Civ.C.)O I<eder'.Name G FL'BLL I— LendersAddress QTY. MECHANICAL PERMIT FEEQWIcenifythatIhavereadthbapphratlonaciststethattheaboveinformation NICAL FEE1 iscorrect.I agree to comply with aB city and county ordinanm and state laws PERMIT M-LIANCE �� ID:} W elating to building construction,and hembyauthorizerepresentativeaofthisZ city to enter upon the above-mentioned property forimpectiun purposes. ALTER ORADDTO MECH.(We)agree to save,indemnify and keep har less theCity ofCupertino `C6 Receipt#against llabllitles,judgments,ontsand expenses which may in anywayamue AIA HANDLING UNIT $U$TOTAL:agaim satd City in consequence of the granting of this permit� AIR HANDLING UNIT(OVERIO,ODOCEM) UCTION TAXIgna rcofA pliant/ ontractor Date EXHAUST HOOD(W/DLJCT) UCTION TAX PAID:HAZARDOUS MATERIALS DISCLOSUREWill the applicant orfumm building ompant store or handle hvardous HEATING UNIT(TO 100,000 Branmatcrulasdefined by the Cupertino Municipal Code,Chapter 9.12,and the RCCeI t#
Health and Sa(ny Cade Section 25532(a)7 H TING UNIT(OVER IOg000 BTU)
equ
❑Yin . N No TOTAL: a
which
cmie appliantorfuture and Wilding ocoupaas defined
�pandbyd use equthe Bay AresI. devices VENTILATION FAN(SINGLE RFSID) ISSUF&rCw�E DATE
which emit ha:a rdous air contamiantsas defined It the Bay Area Air
Quality Management District? BOILER-COMP OTII'OR 100,0(0 BTU)
4 yes T�No
have read the hall ous materials requircmenb under Chapter G95 of BOILER-COMP(OVER 105,000 BTU) /1r/s-� �Q^�
the California Health k SaletyCode,Sections 25505,25533 and 25535. 1 PrC VWv
understand that if the building does not currently have a tenant,that It is my NEWRESIDENTIALMEIN. SQ.Ff
responsibilityce notify the oaae Of ofthe requirements which must be met
prior to Issuance ofa Certificate of Occupanry. Ott to '
Owner or aaflu, mdagent Date MW
TOTAL: 4 ISSUED BY:�J lTW7c1�J Y�/�k�
OFFICE COPY �,